Podiatric Medicine, Behavioral Science, and Ethics
Podiatric Medicine
Foot examination and common conditions
Podiatric medicine integrates history, vascular status, neurologic status, dermatology, and biomechanics. Know the diabetic foot examination: pulses, capillary refill, skin temperature, sensation, and pressure points. Distinguish neuropathic ulcers, usually at pressure-bearing sites with callus and intact pulses, from ischemic ulcers, often painful, punched-out, and associated with poor pulses. Charcot neuroarthropathy presents with a warm, swollen, erythematous foot; infection must be considered, but Charcot can mimic cellulitis. Nail and skin conditions include onychocryptosis, onychomycosis, tinea pedis, and plantar warts.
Traps and worked rules
A common trap is assuming every warm red foot in a diabetic patient is cellulitis. Charcot is a diagnosis of exclusion but must be considered, especially with neuropathy and midfoot collapse. Another trap is treating a neuropathic ulcer without offloading; pressure relief is essential. For warts versus callus, warts disrupt skin lines and may have thrombosed capillaries, while callus preserves skin lines.
Worked example
A diabetic patient has a plantar ulcer under the first metatarsal head with callus, palpable pulses, and reduced monofilament sensation. This pattern favors neuropathic ulcer. The rule of thumb: offload first, then débride and treat infection if present. Probe to bone raises concern for osteomyelitis.
Behavioral Science
Learning, development, and clinical behavior
Behavioral science questions test learning theory, human development, defense mechanisms, grief, substance use, and the doctor-patient relationship. Distinguish classical conditioning, in which a neutral stimulus becomes associated with a reflex, from operant conditioning, in which consequences shape behavior. Positive reinforcement adds a rewarding stimulus; negative reinforcement removes an aversive stimulus; punishment decreases behavior. Know Piaget, Erikson, and attachment concepts at a broad level rather than memorizing isolated trivia.
Traps and worked rules
A frequent trap is labeling negative reinforcement as punishment. Negative reinforcement increases behavior by removing something unpleasant; punishment decreases behavior. Another trap is confusing denial with avoidance or rationalization. In grief, remember that cultural expression varies and that uncomplicated grief is not a disorder simply because symptoms are intense. For substance use, identify withdrawal and intoxication patterns by timing and autonomic signs.
Worked example
A patient avoids taking medication because each dose causes nausea, and the patient stops the drug. This is negative reinforcement of avoidance behavior, not punishment. The rule of thumb: reinforcement increases behavior; punishment decreases behavior. Label the consequence, not the patient's emotion.
Ethics
Principles and clinical application
Ethics questions test autonomy, beneficence, nonmaleficence, justice, confidentiality, informed consent, capacity, surrogate decision-making, and end-of-life care. Informed consent requires disclosure, comprehension, voluntariness, and capacity. Capacity is a clinical determination about understanding, appreciation, reasoning, and expressing a choice; competence is a legal status. Minors generally require parental consent, but exceptions include emergency care, emancipation, and certain public-health situations. Confidentiality can be breached when required by law or when there is a serious threat to an identifiable person.
Traps and worked rules
A common trap is equating a patient's refusal of care with incapacity. A patient with capacity may refuse even life-saving treatment. Another trap is choosing the surrogate by family hierarchy alone; many jurisdictions use a legally designated agent or default statutory order. In emergencies, treatment may proceed without consent if delay would cause serious harm.
Worked example
A patient with capacity refuses amputation despite gangrene. The team should ensure understanding and document the discussion, but cannot override the refusal solely because the team believes amputation is best. The rule of thumb: capacity is decision-specific; a capable patient's informed refusal is honored.